A disabled Sawbridgeworth woman died after an ambulance took three hours to arrive at the hospital she was being cared for at, an inquest heard.

The final inquest into the death of 59-year-old Joan Hughes was held today (Tuesday, March 6) at Hatfield’s Old Courthouse, after it opened last summer.

The court heard that Mrs Hughes was being looked after at the Jacobs and Garden Neurological Centre in Sawbridgeworth, having suffered a catastrophic stroke’ in 2016.

Cause of death contested

While her GP Neil Roberts recorded her death as being caused by pneumonia, a post-mortem examination found otherwise – prompting assistant coroner Edward Solomans to tell Dr Roberts it was “not appropriate to issue such a certificate".

Mr Solomons said: “Knowing she was passing faecal matter through her mouth, how can you conclude the disease or condition leading directly to her death was pneumonia?”

Responding, Mr Roberts told the court that he believed that Mrs Hughes had “died days before” and that quite often the cause of death changes after.

A post-mortem determined 'extensive peritonitis' - an infection of the inner lining of the stomach - as the primary cause of death.

Mr Solomons however turned to the stroke that Mrs Hughes suffered the year before when coming to the conclusion of natural causes.

Mrs Hughes suffered from a natural pontine haemorrhage – a type of stroke which saw her admitted to Queen’s Hospital for treatment on October 6, 2016.

She was later transferred to Basildon University Hospital where it was decided that neurological intervention would not go ahead.

Subsequently, she became a resident of the Jacobs and Garden Neurological Centre in Sawbridgeworth.

Admission to Jacobs Centre

“Many residents have disorders of physical, cognitive abilities, impairment of their conscious levels and so on.”

Following an assessment, that the services offered by the centre would be able to meet Mrs Hughes' needs, she was admitted on June 15, 2017.

“She was a lady who required assistance with all activities of daily living,” continued Ms McCarthy.

“Washing and dressing, moving and handling, tracheostomy care, she had a peg for nutrition and she received support from physiotherapists with things like chest management and subsequently passive exercises.”

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In the likelihood of death, an ambulance would not be needed due to the no resuscitation agreement.

“Even in these conditions people do rally,” continued Dr Roberts.

“We don’t withhold treatment, but it’s about appropriate treating according to her condition.”

Dr Roberts continued to say that he did not expect Mrs Hughes to survive the next 24 hours.

On July 21, 2017, Mrs Hughes was on maximum oxygen and extra antibiotics for her chest.

The court heard that by this stage it was a question as to when she would pass away.

The final inquest into the death of Joan Hughes was held at Hatfield Coroner's Court

Ambulances diverted

Dr Roberts, who was off for the weekend, received a call from one of the nurses at the Jacobs Centre on July 22, to say that Mrs Hughes had developed a bowel obstruction of some sort whether this be twisted, blocked or it had stopped working.

The matter started to work its way through Mrs Hughes' body and she began to vomit.

A 999 call to the East of England Ambulance Service was therefore made and nurses told them it was for a distended abdomen, which was firm and warm to the touch.

Whilst the call was made at 11.48am, due to pressures on the trust, ambulances were continuously diverted meaning that help was not with Mrs Hughes until 3pm.

In a statement read to the court by assistant coroner Edward Solomons the East of England Ambulance Service sincerely apologised for the delay in the ambulance attending and expressed their condolences.